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Invited Commentary
November 4, 2020

Multivessel Percutaneous Coronary Intervention During ST-Elevation Myocardial Infarction—A Dickensian Debate That Never Ends

Author Affiliations
  • 1Interventional Cardiology Group, AdventHealth Ocala, Ocala, Florida
JAMA Cardiol. Published online November 4, 2020. doi:10.1001/jamacardio.2020.5361

“The one great principle of the English law is to make business for itself.” —Charles Dickens, Bleak House1(p548)

When randomized clinical trials (RCTs) began to displace observational studies as the source of evidence for using multivessel percutaneous coronary intervention (PCI) during ST-elevation myocardial infarction (STEMI), guideline committees discovered that they had gotten it wrong. In a total reversal, they elevated the prior class III recommendation (“harm”)2 for multivessel PCI in patients in stable condition to a class IIa recommendation (“should be considered”)3 or a IIb recommendation (“may be considered”),4 and they downgraded the prior class IIa recommendation5 for multivessel PCI in patients with cardiogenic shock to a class III recommendation.3 Is there a better example in medical history of how RCTs and observational studies have generated such diametrically opposed recommendations?